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A Safe Benzodiazepine Guideline for Elderly Inpatients

Hunter New England Local Health District
Project Added:
5 February 2015
Last updated:
11 February 2015

A Safe Benzodiazepine Guideline for Elderly Inpatients

Summary

This project was a result of the Junior Medical Officer (JMO) Quality and Safety Committee. While defining its role in its pilot 12 months, concerns regarding the prescribing of benzodiazepines in the elderly inpatients were identified and acted upon by way of two audits, guideline creation and education packages. 

This project was a finalist in the Translation Research category of the 2014 NSW Health Awards. Download a poster from the 2014 NSW Health Awards.

Aim 

To identify the extent and assessment of appropriately prescribing benzodiazepine, raise awareness about adverse effects and improve and encourage safe prescribing.

Benefits

  • Improved patient outcomes and promotion of good sleep 
  • Improved prescribing guidelines and consideration of hospital environments, patient experience and journey
  • Reduced falls in hospital

Project Status

Sustained: The project has been implemented, is sustained in standard business.

Background

Benzodiazepines are a class of medications that are commonly used, and misused, in the elderly. This is despite benzodiazepines being well known to cause falls, cognitive impairment, and delirium. A team of junior doctors led a multidisciplinary effort to reduce the misuse of benzodiazepines in elderly people who are admitted to hospital.

An audit found nearly two thirds of the benzodiazepine prescriptions reviewed in elderly patients were inappropriate. After broad consultation a NSW-first prescribing guideline for the safe use of benzodiazepines in hospital was developed. 

The adverse effects of benzodiazepines were often overlooked with drugs like temazepam widely considered safe, regardless of the patient. This project stemmed from a series of situations where benzodiazepines were being requested for acute insomnia in patients with a background of falls or delirium.

While looking for evidence to back up clinical judgement about the need to reduce benzodiazepine prescribing, a clear lack of literature and of hospital policy was identified - not just within the Hunter New England (HNE) Health network.

Implementation 

Fostering and promoting collaboration between junior medical personnel, nursing staff, allied health and administrative staff while having a strong evidence base were vital. 

A large scale audit, covering multiple wards and sifting through hand-written drug register entries required personnel, organisation and communication. 

Findings needed to be conveyed to several parties. Support from pharmacy was needed to identify patients, clinicians to endorse the audit, clinical governance to escalate the findings and recommendations along chains of clinicians and committees, and ultimately junior doctors and nursing staff to put the recommendations into place.

Retrospective audit was employed as the main assessment tool. 

Set up by junior doctors in 2013 – the Junior Medical Officer Quality and Safety Committee, was established specifically for projects like this. 

Through this committee the project team was able to streamline communication and collaboration with clinical and non-clinical staff and develop close ties with keen university students, looking to help out with quality improvement projects.

The Junior Medical Officer Quality and Safety Committee was established. While defining its role in its pilot 12 months, concerns regarding the prescribing of benzodiazepines in the elderly inpatients were identified and acted upon by way of two audits, guideline creation and subsequent education packages. This committee, led by JMOs, encourages involvement in common clinical issues linked to patient safety. The guideline can be universally applied to the after-hour’s prescribing that many JMOs face. 

The project used a simple audit tool with proven data collection methods. Some of the original auditors were students and have seen the impact this project has made. This is promising in that we likely have a group of junior doctors who are willing to carry this project on next year and the year after because of their input on the same project as students.

Results 

The clinical prescribing guideline that came about as a direct result of the project provides a clear, succinct pathway for any potential benzodiazepine prescriber to follow. 

The project has boosted productivity in several ways. Most importantly was the confidence it gave junior doctors working for Hunter New England Health in not only auditing but pushing for change. 

The guideline reduces the time spent making decisions regarding benzodiazepines and potentially reduces the adverse event rate, avoiding all the issues with managing excessive falls and delirium (as examples).

Prior to distribution of the guideline, only 30% of benzodiazepines were appropriately prescribed for insomnia. This was improved the following year where 66% of benzodiazepine prescriptions had an appropriate indication. There is now a clear picture of benzodiazepine prescribing in the John Hunter Hospital, and a plan to extend this to other sites within the Hunter New England Health Network.

A comparison of falls statistics over the same two 3-month intervals was also made. Between May and July 2013, there were a total of 177 falls within the John Hunter health service. This had reduced to 156 falls by the period covering April to June in 2014 – a reduction of 11.9%.

This project has generated interest in the promotion of good sleep for inpatients – an issue that requires us to consider how the hospital environment impacts the patient experience and journey. There is recognition that medication is not the solution.

Benzodiazepine guideline and subsequent education has led to an improvement in appropriate prescribing in the John Hunter Hospital, as well as a potential reduction in falls in the same months the audits were conducted.

Lessons Learnt

The issues identified are common across inpatient facilities throughout NSW, and the guideline has the potential to be easily transferred to other facilities. This has been demonstrated at Tamworth Rural Referral Hospital, where a similar implementation progress has been undertaken, and data collection on the impact of this implementation is currently underway. 

This project has resulted in statewide interest in developing a prescribing guideline to limit the harm caused by benzodiazepines, with the Clinical Excellence Commission expressing interest in using the guideline to rollout a similar document throughout NSW.

A similar project, currently at the audit stage, is currently being undertaken by JMOs at Bankstown-Lidcombe hospital.

Contact

Zoheb Williams
Junior Medical Officer
Hunter New England Local Health District (HNELHD)
Ph: 02 43940500
Zoheb.Williams@hnehealth.nsw.gov.au

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